Consent to Proxy Access to GP Online Services

The Patient

(This is the person whose records are being accessed)

Surname: *

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode: *

Please confirm the following: *

The patient has the capacity to consent to grant proxy access.

The patient does not have the capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient's best interest.

I give permission to my GP practice to give the people listed in Section 3 proxy access to the online services as indicated below in Section 2.

I reserve the right to reverse any decision I make in granting proxy access at any time.

I understand the risks of allowing someone else to have access to my health records.

I have read and understood the important information tab regarding online services.

Signature of Patient: *

Date:

Details of access required

I (the patient) consent for the representative to have access to:

I (the representative) request to have access to:

Please tick proxy access required:

Online appointment booking

Changing contact information

Online prescription management

Accessing medical record (excludes ages 11-16)

The Representatives

(These are the people seeking proxy access to the patient's online records, appointments or repeat prescription)

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1.

I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements: *

I/we have read and understood the terms and conditions above and agree that I will treat the patient information as confidential

I/we will be responsible for the security of the information that I/we see or download

I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement

I/we see information in the record that is not about the patient, or is inaccurate, I/wewill contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential

*

I confirm the above and have read and understood the important information tab regarding online services

Your signature(s) *

Representative 1

Date

Your signature(s)

Representative 2

Date

Please upload the patient and the representatives ID. This must be a photo of your head and shoulders, holding your ID. Please ensure we can clearly see your ID in your photo. If the patient is under the age of 12, please submit a photo of the birth certificate.

Maximum upload size: 67.11MB

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Consent to Proxy Access to GP Online Services

The Patient

Details of access required

The Representatives

Healthwatch Oxfordshire